Q1 1-5
Match the common problems seen in respiratory infections with the priority intervention:
Ineffective airway clearance ->
Impaired gas exchange ->
1.Apply oxygen, reduce anxiety, semi-fowler or prone position
2.Reposition, open the airway with jaw thrust, administer ordered bronchodilators and steroids
Ineffective airway clearance -> Reposition, open the airway with jaw thrust, administer ordered bronchodilators and steroids
Impaired gas exchange -> Apply oxygen, reduce anxiety, semi-fowler or prone position
A 2-year-old is brought to the ED with a history of severe coughing fits followed by a “whooping” sound on inspiration and episodes of vomiting after coughing. The nurse suspects pertussis. Which intervention is the priority?
Administer supplemental oxygen as needed
Initiate contact precautions
Encourage frequent deep breathing exercises
Place the child in a negative pressure room
Administer supplemental oxygen as needed
Administer supplemental oxygen as needed
The nurse is assessing a child with a burn injury for signs of cellulitis. Which finding(s) prompts the nurse to perform interventions for cellulitis? Select all that apply.
Fever
Chills
Lymphadenopathy
cold, clammy skin around the infected area
Koplik spots
Fever
Chills
Lymphadenopathy
The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a patient in septic shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary goal of this aspect of treatment?
To prevent the formation of infarcts of emboli
To limit stroke volume and cardiac output
To prevent pulmonary and peripheral edema
To maintain adequate mean arterial pressure (MAP)
To maintain adequate mean arterial pressure (MAP)
An adult patient’s Q 12 hour scheduled IV antibiotic was delayed 2 hours due to lack of IV access. What is the nurse’s best follow‑up action?
Skip the dose and resume the schedule with the next dose due in 10 hours
Administer immediately, document the delay, and reschedule future doses for new administration times to keep Q 12 hour spacing
Request a double dose from pharmacy now to be administered STAT
Administer now and chart that the time given was two hours ago to keep the medication on schedule
Administer immediately, document the delay, and reschedule future doses for new administration times to keep Q 12 hour spacing
The nurse is teaching the parents of a 4-year-old child with impetigo about considerations while the child recovers at home. What will the nurse include in the teaching? Select all that apply.
Notify the day care provider
Teach the child proper handwashing techniques
Call the health care provider if lesions become warm to the touch and more inflamed
Schedule an impetigo vaccination to avoid reinfection
Notify the day care provider
Teach the child proper handwashing techniques
Call the health care provider if lesions become warm to the touch and more inflamed
The nurse is providing teaching to the parents of a child with varicella. Which statement by the parents indicates the teaching was successful?
"We should apply alcohol to the lesions every 4 hours."
"If our child has a fever, we can give them some aspirin."
"The lesions should eventually form soft crusts that drain."
"We need to make sure that our child washes their hands frequently."
"We need to make sure that our child washes their hands frequently."
What is the most worrisome physiologic threat presented by neurological infections?
Decreased cerebral perfusion
Fever
Confusion
Increased mean arterial pressure (MAP)
Decreased cerebral perfusion
An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the patient's infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the patient's risk of septic shock?
Apply an antibiotic ointment to the patient's mucous membranes, as ordered.
Perform passive range-of-motion exercises unless contraindicated
Initiate total parenteral nutrition (TPN)
Rapid initiation of IV antibiotics and close monitoring for early signs of sepsis
Rapid initiation of IV antibiotics and close monitoring for early signs of sepsis
A 53‑year‑old patient is POD 5 after open abdominal surgery for ovarian cancer. She reports increasing tightness beneath her incision and new pain not relieved by her usual analgesics. Her temperature is 38.3°C (101°F). The surgical dressing was clean, dry, and intact yesterday when it was last changed. Which nursing action is the priority to reduce progression of complications?
Administer prescribed PRN oxycodone and reassess in 1 hour
Inspect the surgical incision and surrounding tissue for signs of infection
Encourage the patient to ambulate to improve circulation
Administer an anti-pyretic and reassess the patient's temperature in 60 minutes
Inspect the surgical incision and surrounding tissue for signs of infection
True or false: Breath sounds and noisy breathing may diminish as the child uses remaining energy stores to maintain ventilation in acute respiratory infections. Immediate assessment and intervention should occur when a stridulous or noisy breathing child suddenly becomes quiet.
TRUE
The nurse is performing an assessment on a child. Which finding indicates to the nurse the child is at an increased risk for a urinary tract infection (UTI)?
washing the genital area with water daily
wiping front to back after using the restroom
drinking water and juice during the day
holding urine while at school
holding urine while at school
What is the top nursing priority for neurological infections with an unknown cause?
Establish an IV and administer IV antibiotics ASAP per provider orders
Position the patient in high fowlers
Put patient on seizure precautions
Establish an IV and give antibiotics after all procedures and cultures have been completed, even if delayed
Establish an IV and administer IV antibiotics ASAP per provider orders
What are the most reported reasons that people are vaccine hesitant? Select all that apply.
Worries about vaccine safety
Worries about potential adverse side-effects from the vaccine
Low perceived susceptibility of the illness
Low perceived severity of the illness
Worries about vaccine safety
Worries about potential adverse side-effects from the vaccine
Low perceived susceptibility of the illness
Low perceived severity of the illness
A patient with an implanted port is receiving continuous IV fluids on an oncology unit. During morning assessment, the nurse notes erythema at the needle access site and the patient reports chills overnight. Blood cultures have not yet been drawn. Which nursing action best reflects evidence‑based CLABSI prevention and early response?
Clean the site and reinforce the dressing, then continue fluids
Remove the port needle immediately and notify the infection control nurse
Notify the provider and anticipate blood cultures and IV antibiotics
Slow the IV infusion rate to reduce irritation at the site
Notify the provider and anticipate blood cultures and IV antibiotics
Which of the following are expected outcomes for a child being treated for laryngotracheobronchitis (AKA Croup)?
The child has decreased respiratory distress
Oxygen saturation levels are within normal limits for age and baseline health status
The child has adequate fluid intake for age, as evidenced by adequate urine output for age
Administration of medications improves respiratory status and decreases stridor
ALL OF THE ANSWER CHOICES ARE CORRECT
ALL OF THE ANSWER CHOICES ARE CORRECT
A public health nurse promoting the annual influenza vaccination is focusing health promotion efforts on the populations most vulnerable to death from influenza. The nurse knows the following groups are MOST vulnerable to dying from influenza (select all that apply):
Healthy school aged children
Older adults
Adults with serious comorbidities like diabetes, chronic kidney disease, and cancer
Healthy college students
Older adults
Adults with serious comorbidities like diabetes, chronic kidney disease, and cancer
A medical unit nurse is careful to adhere to infection control protocols, including handwashing. Which statement about handwashing supports the nurse's practice?
Frequent handwashing reduces transmission of pathogens from one patient to another.
Wearing gloves is known to be an adequate substitute for handwashing.
Bar soap is preferable to liquid soap.
Waterless alcohol-based hand gel is used instead of handwashing for enteric precautions.
Frequent handwashing reduces transmission of pathogens from one patient to another.
Which of the following are communication strategies nurses can use with people who are vaccine-hesitant? (select all that apply)
Listen and welcome questions
Spend a lot of time dispelling myths
Tailor communication to situation
Respect autonomy
Listen and welcome questions
Tailor communication to situation
Respect autonomy
A hospitalized patient has profuse watery diarrhea and a history of recent antibiotics. Clostridioides difficile infection is suspected. Which nursing intervention is most appropriate to prevent transmission?
Use alcohol‑based hand sanitizer before and after patient contact
Place the patient on contact enteric precautions with gown and gloves and handWASHING
Assign the patient to a negative‑pressure room
Require surgical masks for all visitors
Place the patient on contact enteric precautions with gown and gloves and handWASHING
The nurse is assessing a 3-year-old child hospitalized for the treatment of pneumonia. Which finding(s) should the nurse act upon as a sign or symptom of possible respiratory failure? Select all that apply.
Difficult to arouse
Hypotension
Skin color appropriate for ethnicity
Able to auscultate air movement
Nasal flaring
Difficult to arouse
Hypotension
True or false: When there is a cardiac infection, it is usually due to a systemic source.
True
A nurse in the ICU is planning the care of a patient who is being treated for septic shock. Which of the following statements best describes the pathophysiology of this patient's health problem?
Blood is shunted from vital organs to peripheral areas of the body.
Cells lack an adequate blood supply and are deprived of oxygen and nutrients.
Circulating blood volume is decreased with a resulting change in the osmotic pressure gradient.
Hemorrhage occurs as a result of trauma, depriving vital organs of adequate perfusion.
Cells lack an adequate blood supply and are deprived of oxygen and nutrients.
A patient receiving IV vancomycin for a serious MRSA infection becomes frustrated when the nurse prepares to draw another blood sample and says, “I don’t understand why you keep taking my blood. You already took it once this morning! Isn’t the medication already working?”
“These blood tests show us that the medication is being fully cleared from your bloodstream before the next dose.”
“The peak and trough levels help us ensure the vancomycin level is high enough to treat the infection but not so high that it causes kidney damage or other toxic effects.”
“Drawing blood before and after the dose confirms that the IV medication was infused at the correct rate.”
“Vancomycin levels are drawn on all patients receiving this medication to prevent antibiotic resistance.”
“The peak and trough levels help us ensure the vancomycin level is high enough to treat the infection but not so high that it causes kidney damage or other toxic effects.”
During peak influenza season, a nurse notices several staff members coming to work mildly symptomatic. A patient later develops influenza after prolonged hospitalization (a hospital acquired infection). Which intervention most effectively breaks the chain of infection at the level of the reservoir?
Administer antiviral medication to the patient
Increase frequency of environmental surface cleaning
Enforce staff vaccination and illness‑related work restrictions
Place the patient on droplet precautions after diagnosis
Enforce staff vaccination and illness‑related work restrictions